The nurse is caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS) whose most recent laboratory values reveal a CD4 level less than 200. Which assessment findings require immediate intervention?

Oral candidiasis and nausea

Genital ulcer and vomiting

Memory deficit and apathy

Progressive dyspnea and fever

Answer and Explanation

The Correct Answer is D

A. Oral candidiasis and nausea: Oral candidiasis (thrush) and nausea are common manifestations in patients with AIDS, particularly when the CD4 count is low. While these symptoms require intervention, they are not typically considered emergent or immediately life-threatening.

B. Genital ulcer and vomiting: Genital ulcers and vomiting can occur in patients with AIDS due to various opportunistic infections and conditions. While these symptoms may warrant intervention, they are not typically indicative of an immediate life-threatening situation.

C. Memory deficit and apathy: Memory deficits and apathy can occur in patients with AIDS, particularly as the disease progresses. While these cognitive and behavioral changes may impact the patient's quality of life and require intervention, they are not typically considered emergent or immediately life-threatening.

D. Progressive dyspnea and fever: Progressive dyspnea (difficulty breathing) and fever are concerning findings in a patient with AIDS, especially with a CD4 count less than 200. These symptoms may indicate the presence of opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP), which can rapidly progress and lead to respiratory failure and death if not promptly treated. Therefore, these assessment findings require immediate intervention to assess for and manage potential respiratory compromise and systemic infection.

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Correct Answer is D

Explanation

A. Urinary retention: While urinary retention can occur in conditions such as benign prostatic hyperplasia or neurogenic bladder, it is not a typical manifestation of hypertensive emergency. Hypertensive emergencies primarily involve acute and severe elevations in blood pressure, which can lead to target organ damage, but urinary retention is not a direct consequence.

B. Headache: Headache is a common symptom associated with hypertension, especially during hypertensive emergencies. However, it is not specific to hypertensive emergencies and can occur in less severe cases of hypertension as well.

C. Jaundice: Jaundice is not a typical manifestation of hypertensive emergency. It is more commonly associated with liver dysfunction or hemolytic disorders rather than acute elevations in blood pressure.

D. Tachycardia: Tachycardia, or an elevated heart rate, is a hallmark sign of hypertensive emergency. When blood pressure rises significantly, the heart may respond by increasing its rate to maintain cardiac output. Tachycardia is indicative of the body's compensatory mechanisms in response to the acute hypertension and can be a sign of impending cardiovascular complications.

Correct Answer is ["200"]

Explanation

Infusion rate (mL/hr) = 100/30 × 60

Infusion rate (mL/hr) = 100/30 × 60 = 200

Therefore, the nurse should set the IV pump to deliver 200 mL/hr.

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The nurse is caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS) whose most recent laboratory values reveal a CD4 level less than 200. Which assessment findings require immediate intervention?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient who is complaining of blurred vision. The patient's blood pressure reading is 195/130, the heart rate is 95 beats per minute. Which assessment finding by the nurse is consistent with a diagnosis of hypertensive emergency?

Correct Answer is D

Explanation

Correct Answer is ["200"]

Explanation

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